Application for Use of Facilities
Application Is Contingent Upon Approval
Title of Event __________________________________________________________________________________________
Event Type (check one)
Student Sponsored
Academic Course Related
External
University Sponsored
Co-Sponsored
Index No._______________________________
MTSU Affiliated Organization_____________________________________________________________________________
Non-Affiliated/External Organizations (if applicable)__________________________________________________________
Total Event Expected Head Count____________________ Age Group of Participants ___________________________
Individual to be present and responsible____________________________________________________________________
MTSU ID M# (if applicable)_____________________________ Cell No. (_________ ) _________ - ________________
Date(s) Requested______________________________________________________________________________________
Event Set-up Time__________ Start Time__________ End Time__________ Breakdown Time________________
Location Requested________________________ Room_____________ Room Expected Head Count_______________
Date(s) Requested______________________________________________________________________________________
Event Set-up Time__________ Start Time__________ End Time__________ Breakdown Time________________
Location Requested________________________ Room_____________ Room Expected Head Count_______________
Date(s) Requested______________________________________________________________________________________
Event Set-up Time__________ Start Time__________ End Time__________ Breakdown Time________________
Location Requested________________________ Room_____________ Room Expected Head Count_______________
Set-up and
Special Needs
Event Resources Requested
(check all applicable)
Open to General Public
Tickets Required
Admission/Registration Fee
Chairs
Tables
Yes
Yes
Yes
Audio DVD/Film/Video No
No
No
Outdoor Sound
PowerPoint
Products for Purchase
Distributing Advertising Materials
Minor Participating
Food
Special Parking
Yes
Yes
Yes
No
No
No
Some services are venue specific. Additional forms may be required. Additional charges may apply.
Event Description
Event Category (check one)
Agriculture
Do Not Publicize
Alumni
Arts
Faculty/Staff Meeting
Athletics
Conference/Camp/Lecture
Recreation/Wellness
Testing
Student Activity/Event
Other_____________________________________________________________________________________________
Event Website__________________________________________________________________________________________
Page 1–Signatures required on page 2, both pages required
Application for Use of Facilities • Middle Tennessee State University • Murfreesboro, Tennessee
Title of Event __________________________________________________________________________________________
Requestor/Sponsor Contact
Billing Information (If different than requestor)
Name___________________________________________ Name___________________________________________
Phone (____) ____ - _______ Fax (____) ____ - _______
Phone (____) ____ - _______ Fax (____) ____ - _______
Address__________________________________________ Address__________________________________________
City______________________ State______ Zip_________ City______________________ State______ Zip_________
Email____________________________________________ Email____________________________________________
Applicant understands that filing of this application shall constitute agreement by applicant to the following conditions:
1. The intended use of campus property and facilities by applicant does not violate, and actual use will not violate, the provisions of Institution’s Use of Campus Property and Facilities Scheduling Policy (MTSU Policy I:01:06), or any other policies or regulations of the Institution or the Tennessee Board of Regents or any federal state, or local law or regulation.
2. Any use of campus property and facilities pursuant to this application which is contrary to such policies, laws, or regulations of which is inconsistent with the activity as described in this application constitutes grounds for the Institution to remove the activity from campus property.
3. Applicant agrees to indemnify the Institution and hold it harmless from all liabilities arising out of applicant’s use of institution property and/or facilities, including but not limited to personal injury, property damage, courts costs, or attorneys fees.
4. User agrees to furnish proof of insurance or performance bond upon request by the Institution as required by MTSU Policy I:01:06.
5. Affiliated Entities are responsible for all activities that they sponsor that involve nonaffiliated Entities/Individuals, including all event communications with the appropriate scheduler
through this application as well as the conduct of the nonaffiliated Entities/Individuals.
6. Requestor agrees to pay required deposit upon receipt of confirmation. Amount of estimated charges and deposit will be forwarded to requestor once they have been calculated.
7. If the User and/or its Agents will accept credit or debit cards in connection with its performance under this Agreement, User agrees that it will at all times during the performance of this Agreement comply with current Payment Card Industry Data Security Standards (PCI DSS).
Applicant acknowledges that the Institution has made a copy of its Use of Campus Property and Facilities Scheduling Policy (MTSU Policy I:01:06) available for review
at http://www.mtsu.edu/policies/ and understands that a physical copy of such policy will be provided upon request and payment of reasonable copying charges.
Requestor Signature_________________________________________________________ Date______________________
Authorization____________________________________ ________________________________ Date______________
Department Dean / Administrative Officer / Advisor Signature
Print Name
Authorization Email_____________________________________ MTSU Authorization Phone_______________________
Student Affairs Authorization (required for Student Organizations only)
Approved Disapproved
_______________________________________________ ________________________________ Date______________
Leadership and Service OR Office of Fraternity and Sorority Life Signature
Print Name
FOR OFFICIAL USE ONLY • DO NOT WRITE BELOW THIS LINE
R25#
Facility Authorization
Disapproved
Approved _______________________________________________ ________________________________ Date______________
Administrative Authorization
Print Name
Approved Disapproved
_______________________________________________ ________________________________ Date______________
Print Name
Notes
Administration Fee $_____________________
Building Attendant $_____________________
Chairs$_____________________
Custodial/Grounds$_____________________
Production Services $_____________________
Parking Attendant $_____________________
Security$_____________________
Tables$_____________________
Technician$_____________________
Venue Fee $_____________________
Page 2 – Both pages required
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0213-516 – MTSU is an AA/EEO employer.